The shape of the HIV/AIDS epidemic in Puerto Rico

The shape of the HIV/AIDS epidemic
in Puerto Rico
Maria A. Gomez,1 Diana M. Fernandez,1 Jose F. Otero,1
Sandra Miranda,2 and Robert Hunter1

ABSTRACT

In 1992 the noted researcher Jonathan Mann and colleagues of his said
that the global HIV/AIDS epidemic
was still volatile, dynamic, and unstable; that its major impacts were yet to
come; and that its shape and future
depended on individual and collective

1

2

Universidad Central del Caribe, Internal Medicine
Department, Retrovirus Research Center, Bayamón, Puerto Rico. Send correspondence to: Maria
A. Gomez, Retrovirus Research Center, Internal
Medicine Department, Universidad Central del
Caribe, Bayamón, Puerto Rico 00960-6032. Telephone: (787) 787-8710; fax: (787) 787-8733; e-mail:
mgomez@caribe.net
Commonwealth of Puerto Rico, Health Department, Puerto Rico AIDS Surveillance Program, San
Juan, Puerto Rico.

This study presents information on AIDS patients in Puerto Rico, including their general sociodemographic profile, some risk-related parameters, characteristics of vulnerable groups, and
elements of the clinical spectrum of the disease. Data were analyzed from the Puerto Rico AIDS
Surveillance Program and available studies about the HIV/AIDS epidemic in Puerto Rico. A
total of 23 089 AIDS cases was reported to the Puerto Rico AIDS Surveillance Program from
January 1981 through February 1999. The HIV/AIDS epidemic has affected mostly males and
females between the ages of 30 and 49, though cases have also been reported for other age groups.
The cumulative proportion of persons with AIDS who are women has increased tremendously,
from 11.4% for the 1981–1986 period to 21.6% for the entire 1981–1999 period. In Puerto Rico
the category of injecting drug users (IDUs) accounts for the majority of the AIDS cases (52%),
followed by heterosexual contact (22%), and men who have sex with men (17%). The three
main diagnoses for AIDS on the island are wasting syndrome (30.7%); esophageal, bronchial,
and lung candidiasis (29.4%); and Pneumocystis carinii pneumonia (26.8%). According to
1994 vital statistics for Puerto Rico, AIDS was the fourth-leading cause of death. The overall
reported AIDS mortality rate was 42.0 per 100 000 persons, with the rate for males, 67.8,
much higher than it was for females, 17.4. AIDS is the first cause of death among persons between 30 and 39 years old. Intense efforts are needed to better understand the epidemic in
Puerto Rico and its biology, social and family impacts, and financial costs.

human behavior (1). Since then, considerable progress has been made in
understanding the HIV/AIDS epidemic, the determinants and distribution of that epidemic in different populations, the clinical spectrum of the
epidemic, and its synergistic effects
with other epidemics. Nevertheless,
there is much that needs to be better
understood.
Estimates of the magnitude of the
epidemic are generally based on reported AIDS cases, which are believed
to be underreported around the world.
In 1992, according to the World Health
Organization (WHO), 12.9 million people around the world were infected

Rev Panam Salud Publica/Pan Am J Public Health 7(6), 2000

with the HIV virus. According to a
WHO report from December 1998,
over the ensuing six years, the number
of people infected rose to 33.4 million,
an increase of 159% (2). The Joint
United Nations Programme on HIV/
AIDS (UNAIDS) and WHO estimated
that 16 000 persons per day became
HIV-infected during 1998 (3). Up
through December 1998, 41.6% of all
AIDS cases had died, with 2.5 million
deaths in 1998 alone.
Even as different aspects of the epidemic are better defined and there is
an immense global effort against HIV
and AIDS, the HIV virus continues to
spread. This is particularly true in the

377

developing world, where more than
95% of all HIV-infected people live.
UNAIDS and WHO have reported that
in most of Latin America and the Caribbean the pattern of HIV spread is much
the same as in industrialized countries,
with the main modes of transmission
being men having unprotected sex
with other men, and injecting drug
users (IDUs) sharing needles (3).
In Puerto Rico a total of 23 089 AIDS
cases was reported to the Puerto Rico
AIDS Surveillance Program from January 1981 through February 1999 (4).
According to data from the United
States Centers for Disease Control and
Prevention (CDC), Puerto Rico had the
fourth-highest incidence of AIDS cases
among the states and territories of the
United States of America during the
period of July 1997 through June 1998
(5). The rate for Puerto Rico, 52.8 per
100 000 inhabitants, was only exceeded
by the incidence rates in the District of
Columbia (178.3), the state of New
York (62.5), and the U.S. Virgin Islands
(55.9).
Similar results come from looking at
data for the major metropolitan areas
of the United States with the highest
incidence of AIDS cases over a period
of several years, including San Juan,
Puerto Rico’s capital and largest city
(Table 1). Of the seven metropolitan
areas shown in Table 1, San Juan was
the only one that showed an increase
for the 12-month period ending with
June 1997. And while all seven of the
metropolitan areas showed decreases
in incidence rates for the 12 months
ending in June 1998, San Juan had the
smallest of those declines (5).
The objective of the present study
is to present information on AIDS patients in Puerto Rico, including a general sociodemographic profile, riskrelated parameters, and characteristics
of groups that are particularly vulnerable. The study also covers elements of
the clinical spectrum of the disease.
For our study, we analyzed data
from the Puerto Rico AIDS Surveillance
Program and available studies about
the HIV/AIDS epidemic in Puerto
Rico. According to data from the
Puerto Rico AIDS Surveillance Program (6), the largest number of AIDS

378

TABLE 1. Metropolitan areas of the United States of America with the highest incidence of
AIDS cases (per 100 000 population) in the preceding 12 months
Metropolitan area

June 1996

June 1997

June 1998

New York, New York
Miami, Florida
Jersey City, New Jersey
San Francisco, California
Fort Lauderdale, Florida
West Palm Beach, Florida
San Juan, Puerto Rico

131.0
115.5
114.5
108.5
86.4
85.3
66.3

117.2
86.6
109.8
83.1
78.4
73.0
70.2

101.2
76.4
72.2
69.7
56.2
53.9
63.3

Source: United States, Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report, June 1998.

TABLE 2. AIDS exposure categories in Puerto Rico among adults and adolescents, January
1981–February 1999a
Males

Females

Total

Exposure category

No.

%

No.

%

Injecting drug use
Men who have sex with men
Heterosexual contact
Men who have sex with men and
inject drugs
Receipt of blood transfusion,
blood components, or tissue
Risk not reported/Other

9 791
3 797
2 130

55
21
12

1 908
0
2 901

39
0
58

11 699
3 797
5 031

52
17
22

1 690

10

0

0

1 690

7

101
182

1
1

122
57

2
1

223
239

1
1

Total no. of cases

17 691

4 988

No.

%

22 679

Source: Puerto Rico AIDS Surveillance Program.
a This table does not include 410 pediatric cases, for whom exposure categories were different.

cases on the island from January 1981
through February 1999 were in the
health regions of San Juan (5 791 cases),
Ponce (3 969), and Bayamón (3 841).

male with AIDS, there were two adolescent males with the syndrome. That
male-female ratio increased with age.
For example, for those aged 30 to 39
years, the ratio was 3.3:1 (7).

SOCIODEMOGRAPHIC
SPECTRUM

BEHAVIORAL SPECTRUM

Information from the Puerto Rico
AIDS Surveillance Program showed
that between January 1981 and February 1999, 45% of all the reported AIDS
cases had occurred among those 30–39
years old, 24% among those 40–49
years old, 18% among those 20–29
years old, and 11% among those 50 and
older (4). Among adolescents in Puerto
Rico, from January 1981 through September 1996, for every adolescent fe-

There are differences in HIV exposure categories between the continental United States and the island of
Puerto Rico. Information from the
Puerto Rico AIDS Surveillance Program (4) shows that in Puerto Rico the
category of injecting drug users (IDUs)
accounts for a slight majority of the
cases (52%), followed by heterosexual
contact (22%) and men who have sex
with men (17%) (Table 2). In contrast,

Gomez et al. • HIV/AIDS in Puerto Rico

in the continental United States the
main exposure category among adults
and adolescents continues to be the
men having sex with men (48%), followed by IDUs (26%) and by heterosexual contact (10%) (5). Thus the risk
profile of HIV/AIDS patients in Puerto
Rico is similar to the one for Western
Europe, North Africa, and the Middle
East (2).
Differences between gender and exposure categories are also found between Puerto Rico and the mainland
United States. In Puerto Rico the most
frequent exposure category among
males is injecting drug use (55%), followed by men having sex with men
(21%). In contrast, in the continental
United States the most frequent exposure category among males is men
who have sex with men (57%), followed by IDU (22%). Among females,
the first exposure category in Puerto
Rico is heterosexual contact (58%), followed by IDU (38%). In the mainland
United States the rankings are reversed, with 43% for IDU and 39% for
heterosexual contact. In Puerto Rico,
one study of HIV patients showed that
a large proportion of them combined
risk practices, in particular the use of
injecting drugs and heterosexual activity with different partners (8).

Injecting drug use
Recent literature has shown the
growing significance of injecting drug
use in the HIV/AIDS epidemic in
Puerto Rico, as well as among Puerto
Ricans residing in the continental
United States (9–13). Preliminary data
from the Human Retrovirus Registry
of the Universidad Central del Caribe
in Bayamón, Puerto Rico, has demonstrated that injecting drug users are
exposed to many more risk situations
than are other risk groups involved in
the epidemic (14). According to data
from that registry, in Puerto Rico IDUs
have a mean age of 35 years, and most
are males. The IDUs have a spectrum
of social vulnerabilities, including unemployment, a very low educational
level, multiple heterosexual contacts,
and work as prostitutes.

TABLE 3. Clinical spectrum of AIDS in Puerto Rico, January 1981 through February 1999
Most frequent disease categories

Number of casesa

% of patientsa

Wasting syndrome
Esophageal, bronchial, and lung candidiasis
Pneumocystis carinii pneumonia
Toxoplasmosis of the brain
Pulmonary tuberculosis
Kaposi’s sarcoma
HIV encephalopathy

7 089
6 782
6 181
1 365
874
997
475

30.7
29.4
26.8
5.9
3.8
4.3
2.1

Source: Puerto Rico AIDS Surveillance Program.
a Including definitive and presumptive diagnoses, according to criteria of the U.S. Centers for Disease Control and Prevention.
Diagnoses were not mutually exclusive, so the same individual could be reported more than once.

CLINICAL SPECTRUM
The natural history of the disease
and the clinical expression of HIV
ranges from asymptomatic to mild,
moderate, and severe conditions indicative of AIDS. The interval between
initial HIV infection and first symptoms and then AIDS varies from individual to individual. Likewise, the clinical expression of disease also varies
according to individual characteristics
and modes and rates of transmission.
The clinical spectrum of AIDS in
Puerto Rico is presented in Table 3.
This table used data from the Puerto
Rico AIDS Surveillance Program for
the period of January 1981 through
February 1999 (4). The table includes
only the most frequent disease categories, in accordance with the 1993
CDC criteria for AIDS diagnosis (15).
The CDC clinical criteria included presumptive and definitive diagnoses for
specific opportunistic infection and
disease categories. The three main diagnoses in the Puerto Rican population
were wasting syndrome; esophageal,
bronchial, and lung candidiasis; and
Pneumocystis carinii pneumonia (PCP).
Toxoplasmosis, pulmonary tuberculosis, and Kaposi’s sarcoma were also
frequently reported. The clinical categories reported in Table 3 were not
mutually exclusive, so that the same
individual could be counted more than
once. The 1993 CDC criteria for AIDS
diagnosis also included the immunological criteria of CD4 cell counts of
less than 200/µL and/or CD4 percent-

Rev Panam Salud Publica/Pan Am J Public Health 7(6), 2000

ages of less than 14%; that was true for
44.7% of the Puerto Rican AIDS population (4).
In the Human Retrovirus Registry
of the Universidad Central del Caribe
in Bayamón, great emphasis has been
placed on the study of the natural
history of HIV and AIDS. From May
1992 to December 1997 a total of 1 959
HIV/AIDS patients were recruited for
a prospective longitudinal study (8).
Based on the 1993 CDC definition, at
first encounter 960 of the subjects (49%)
had sufficient clinical or immunological criteria to be considered AIDS cases.
Among the 960 AIDS cases, 595 of them
presented with clinical AIDS and 365
persons were classified as AIDS cases
due to low CD4 counts alone. Among
the 595 persons with clinical AIDS, the
most common infections detected were
(by definitive and presumptive CDC
criteria): Pneumocystis carinii pneumonia, 229 cases (38.5%); nonoral candidiasis, 169 (28.4%); toxoplasmosis, 121
(20.3%); wasting syndrome, 98 (16.5%);
and tuberculosis, 71 (11.9%). (Different
clinical diagnoses could be present in
the same individual, so the total number added to more than 595 and the
total percent to more than 100%).
The most prevalent non-AIDS opportunistic infections diagnosed among
the HIV/AIDS patients were thrush
(28.8%), bacterial pneumonia (16.8%),
and skin infections (5.1%) (8).
An improved quality of life and extended patient survival can come from
an early diagnosis of HIV, improved efficacy in the early treatment of the in-

379

fection, and prophylactic measures for
some opportunistic infections. The
time from HIV exposure to onset of
disease is highly variable, as is the
time from diagnosis of AIDS to death.
Some HIV-infected individuals develop
rapidly progressive disease, while others remain relatively symptom-free for
as long as 10 years after seroconversion.
Although numerous studies have examined the influence of transmission
mode on disease progression, no definitive evidence has been given for faster
or slower progression among members
of one risk category or another.
The survival of Puerto Rican patients has been studied. One investigation used the Kaplan-Meier procedure
in analyzing median survival time (7).
The median survival time after diagnosis was 15.5 months for males (95%
confidence interval: 14.8–16.3 mo) and
22.8 months for females (95% CI: 20.6–
25.3 mo). Another study, with AIDS
patients from the San Juan Standard
Metropolitan Statistical Area, also
showed a shorter survival time for
males than for females, 16.4 months
(95% CI: 15.3–17.4 mo) versus 22.7
months (95% CI: 19.9–26.9 mo) (16).
Another study compared the mortality of wasting syndrome versus
Pneumocystis carinii pneumonia in
AIDS patients in Puerto Rico (17).
Controlling for gender, age, and CD4
levels, the investigation found a higher
mortality among the PCP patients.
A study with HIV/AIDS patients in
the Bayamón health region of Puerto
Rico reported a median survival time
of 17.5 months for men and women
and suggested that the patients’ CD4
cell counts and ages were among the
strongest determinants of survival
after an AIDS diagnosis.3
Studies that describe the effects of
newer antiretroviral therapies, with
particular emphasis on protease inhibitors, are lacking for HIV-infected
patients living in Puerto Rico. It may

3

Hunter RF, Miniño A, Gomez MA. Determinations
of survival time from AIDS diagnosis to death in a
cohort of HIV-infected Puerto Rican patients [conference presentation]. 6th NIH/RCMI International AIDS Symposium, San Juan, Puerto Rico,
1998.

380

be logical to assume, as has been
found elsewhere, that patient survival
is extended.

SPECIAL GROUPS
In 1994 the estimated population of
Puerto Rico was some 3.6 million, of
whom 52.5% were female and 47.5%
were male (18). The general mortality
rate that year was 771 per 100 000 inhabitants, with AIDS as the fourthleading cause of death. The AIDS mortality rate had risen from 39.6 per
100 000 in 1993 to 42.0 per 100 000 in
1994. For the year 1994, the mortality
rate for males was higher (67.8 per
100 000) than for females (17.4 per
100 000). In 1994 AIDS was the first
cause of death among persons between 30 and 39 years old and also
the most frequent cause of death in
males up to 49 years of age. The subsections below describe the toll that
the HIV/AIDS epidemic has taken on
some special groups.

Women
The number of HIV-infected women
has increased rapidly in the United
States and the rest of the world (19,
20). In the United States, the proportion of women among AIDS cases increased from 7% in 1985 to 18% in 1994
(19). Between 1991 and 1995 the number of women in the United States
diagnosed with AIDS rose by 63%, a
larger percentage increase than for any
other group with the disease (21). A
similar pattern has been noted in
Puerto Rico, where the number of
women with AIDS reported to the
Puerto Rico AIDS Surveillance Program has been increasing steadily. Between January 1981 and February
1999, a total of 4 988 cases of AIDS
among women were reported, comprising 21.6% of the island’s reported
AIDS cases (4). That is nearly double
the proportion of cases that women
made up during the five years between 1981 and 1986, 11.4% (4).
Along with the increase in AIDS
cases among women has come a rise

in mortality. In the United States in
1994, AIDS was the third-leading
cause of death among women between
25 and 44 years old; in 1996, AIDSrelated mortality among women rose
by 3%, while falling by 15% among
men (20). In Puerto Rico in 1994, AIDS
was the leading cause of death in
women between the ages of 25 and 39,
and it was the fifth most frequent
cause of death among Puerto Rican females, with a mortality rate of 39.6 per
100 000 inhabitants (18). Furthermore,
this toll is likely to continue rising,
given the evidence that women are
more at risk of HIV infection than are
men when considered either on a percontact or per-partnership basis (1).
The routes of HIV transmission,
clinical manifestations, survival time,
and impact on reproductive health differ for women and men (19, 20). While
the impact HIV has on women is multifaceted (18, 22), few studies have
been done on the natural history of the
disease among Hispanic females (21,
22–24). One study of AIDS among
Puerto Rican women in the San Juan
Standard Metropolitan Statistical Area
used data between 1981 through 1995
(16). The male-female ratio found was
3.8:1. The predominant mode of exposure among the women was heterosexual contact (48.7%), followed by intravenous drug use (43.3%). Over that
time period an increasing number of
women reported heterosexual contact
as the mode of exposure to AIDS; between 1993 and 1995, that proportion
rose from 45% to 64%.
Another study analyzed characteristics of 374 Puerto Rican women enrolled in the Human Retrovirus Registry of the Bayamón health region.4
The mean age of women in this sample
was 35 years; 75% of them were in
their childbearing years, and many
were not involved with a regular partner. In addition, a high proportion of
them were unemployed and had lim-

4

Gomez MA, Fernandez D, Otero JF, Hunter RF.
HIV/AIDS in Puerto Rican women: spectrum of
psychosocial, behavioral and clinical vulnerabilities [conference presentation]. 6th NIH/RCMI International AIDS Symposium, San Juan, Puerto
Rico, 1998.

Gomez et al. • HIV/AIDS in Puerto Rico

ited education. Almost half of this
population reported having had heterosexual relations with an HIVinfected partner, and a similar proportion reported having had heterosexual
relations with an injecting drug user.5
These results reinforce other research
indicating that a large proportion of
women with AIDS are IDUs or the sexual partners of IDUs, and also showing that an increasing number of their
children are infected (23).
The women in the Bayamón Retrovirus Registry research presented a
wide spectrum of psychological vulnerabilities. They sustained frequent
episodes of anxiety, confusion, and depression. For all women, living with
HIV/AIDS has an immense psychological impact, given the threat of physical
deterioration and death, the stress of
changes in lifestyles and roles, and the
exacerbation of economic and social
burdens (25–27). The impact is even
more devastating among minority
women, who confront restricted social
roles, have more limited education levels, and deal with potential cultural
barriers related to sexual issues (24, 28).
Of the women enrolled in the Bayamón Retrovirus Registry, more than
half had arrived at the health care facilities at a late stage of the infection and qualified as AIDS cases. These
results were consistent with other research indicating that women seek
HIV/AIDS health care later than men
do (27). Other studies have described
some of the reasons for these delays
(28–30). Symptoms may be misinterpreted and the HIV infection not identified. Women involved in care-giving
act in detriment to their own health
care needs. Some women do not consider HIV a likely diagnosis of their
condition.

Children and adolescents
Pediatric AIDS represents one of the
saddest consequences of the epidemic.
5

Gomez MA, Fernandez DM, Hunter RF. HIV risk
scenario among Puerto Rican HIV/AIDS women
[conference presentation]. 6th NIH/RCMI International AIDS Symposium, San Juan, Puerto Rico,
1998.

In Puerto Rico 410 pediatric AIDS
cases were reported from January 1981
through February 1999. Of these children, 92% acquired the infection from
their mothers, and the rest were infected by contaminated blood or blood
products (4).
AIDS is one of the five leading
causes of death in Puerto Rico among
persons aged 15 years or younger, and
it is the second-leading cause of death
among those 2–9 years old (20). The
majority of these children come from
homes where one or both parents have
a history of drug use or of risky sexual
activities. These families have multiple
needs and will often have to rely on
external sources of assistance (31).
In most countries around the world
the majority of new HIV infections
occur in people between the ages of
15 and 24, often resulting from risky
sexual behaviors. It has been suggested that adolescents are experiencing sexual relations very early in life
and are frequently exposed to unprotected intercourse.

carried out to assess the characteristics
of a subgroup of 123 HIV patients 55
years and older within a larger cohort
study in the Human Retrovirus Registry of the Bayamón health region.6
Preliminary results revealed that only
23 of these elderly persons (18.7%)
were employed. Among the persons
in this subgroup 67% of the females
and 52% of the males reported having
heterosexual sex with a risky partner,
and 22% of the males said they had
had sex with other males. In addition,
17% of the females and 43% of the
males had used injectable drugs;
fewer than 1% of them had received a
blood product transfusion. Within the
preceding year 21% had been diagnosed or treated for depression and
18% for anxiety. Other stress events
affecting their lives included lost income or other significant economic
problems (20%) and the death of a person close to them (17%).

Older persons

The economic impact of HIV/AIDS
can be enormous for the individual
and the family, with such expenses as
hospitalization, ambulatory and emergency care, and prescription medicines. The capacity to work is reduced
and income is often lost. A recent
study of Puerto Rican AIDS patients
revealed that most of them were unemployed and that their incomes had
fallen significantly (8). The social and
psychological impact of AIDS is also
enormous, with caregivers, family members, and loved ones having to meet
AIDS patients’ needs.
Intense efforts are needed to better
understand the biology of AIDS and
the social, economic, and familial impacts of the epidemic in Puerto Rico.
Research leadership in social and behavioral issues is required to translate
the understanding of the dynamics

In Puerto Rico an increasing number of HIV infections have been found
among older individuals. Data from
the Puerto Rico AIDS Surveillance
Program indicate that from January
1981 through February 1999, 11% of
the adults registered with AIDS were
aged 50 years or older (4). In the
United States this older population is
usually not perceived as being at risk
for HIV infection and is generally left
out of targeted prevention programs
(32). That is in spite of the fact that an
estimated 10% of the persons in the
United States aged 50 or older have at
least one risk factor for HIV infection
(33). Physicians also tend to underestimate the possibility of HIV infection
in this population and may have inadequate knowledge concerning their
risk factors (34–35). All this may be
contributing to a pattern of late detection of the disease among these older
individuals.
In order to better understand this
age group in Puerto Rico, a study was

Rev Panam Salud Publica/Pan Am J Public Health 7(6), 2000

SOCIAL IMPLICATIONS OF AIDS
IN PUERTO RICO

6

Gomez MA, Miniño A, Hunter R. HIV/AIDS in a
late-middle aged and elderly Puerto Rican population [conference presentation]. National HIV Prevention Conference, Atlanta, Georgia, 1999.

381

and impact of the epidemic into coherent social and public health action. A
key step in that direction would be for
medical schools and for university behavioral and social science departments that serve minority students to

include a comprehensive curriculum
in AIDS-related issues.

Acknowledgments. This research
effort was supported by grant G12 RR

03035 from the National Institutes
of Health/Research Centers for Minority Institutions and by grant U62/
CCU206209 from the Adult Spectrum
of Disease Project of the U.S. Centers
for Disease Control and Prevention.

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Manuscript received on 13 October 1999. Revised version
accepted for publication on 8 February 2000.

Gomez et al. • HIV/AIDS in Puerto Rico

RESUMEN

El estado de la epidemia de
VIH/SIDA en Puerto Rico

Este estudio presenta información sobre los pacientes con sida en Puerto Rico, como
su perfil sociodemográfico general, los factores de riesgo, las características de los
grupos vulnerables y los elementos del espectro clínico de la enfermedad. Los datos
analizados procedían del Programa de Vigilancia del sida en Puerto Rico y de estudios sobre la epidemia de VIH/sida en la isla. De enero de 1981 a febrero de 1999 se
habían comunicado a dicho programa 23 089 casos de sida. La epidemia de VIH/
sida ha afectado sobre todo a varones y hembras de 30 a 49 años, aunque también se
han descrito casos en otros grupos de edad. La proporción acumulada de pacientes
del sexo femenino con sida ha aumentado enormemente, de 11,4% en el período
1981–1986 a 21,6% en el período 1981–1999. En Puerto Rico, el grupo de adictos a drogas por vía parenteral representa la mayoría de los casos de sida (52%), seguido de los
heterosexuales (22%) y de los varones homosexuales (17%). Los tres diagnósticos de
sida establecidos con mayor frecuencia en la isla son el síndrome consuntivo (30,7%),
la candidiasis esofágica, bronquial y pulmonar (29,4%) y la neumonía por Pneumocystis carinii (26,8%). De acuerdo con las estadísticas demográficas de 1994 en Puerto
Rico, el sida constituyó la cuarta causa de muerte. La tasa global de mortalidad por
sida fue de 42,0 por 100 000 habitantes, siendo mucho más elevada en los hombres
(67,8) que en las mujeres (17,4). El sida es la primera causa de muerte en personas
de 30 a 39 años de edad. Serán necesarios grandes esfuerzos para comprender mejor
la epidemia en Puerto Rico, su biología, su impacto social y familiar y sus costes
financieros.

Rev Panam Salud Publica/Pan Am J Public Health 7(6), 2000

383

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